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General NPI Number Information
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NPI Number | 1922379056
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Entity Type | Organization
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Legal Business Name | THE COOLEY JACKSON FOUNDATION
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Dates
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Enumeration Date | 01/20/2012
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Last Update Date | 01/20/2012
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Provider Practice Location Address
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Address Line | 1081 LAKESHORE DR
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City | CAMDEN
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State | NJ
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Zip | 08104-2627
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Country | US
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Telephone | 856-912-9404
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Fax |
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Provider Business Mailing Address
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Address Line | 1081 LAKESHORE DR
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City | CAMDEN
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State | NJ
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Zip | 08104-2627
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Country | US
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Telephone | 856-912-9404
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Fax |
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | MR. LAMONT JACKSON
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Credential | MBA
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Telephone | 856-912-9404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State | NJ
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